Chronic idiopathic inflammatory bowel disease (IBD) predisposes to the development of colorectal carcinoma. Current preventive measures to diminish colorectal cancer mortality in IBD patients consist of periodic surveillance colonoscopies with random biopsies combined with total colectomy if dysplasia or neoplasia are found. However, challenges regarding management and early detection of inflammatory bowel disease-associated neoplasia (IBDN) still remain. Precancerous dysplastic lesions still escape detection. Morphologic alterations associated with chronic inflammation make dysplasia difficult to diagnose and prone to subjective interpretation. In addition, sporadic colorectal adenomas and adenocarcinomas may also develop in the setting of IBD. Distinguishing between IBD-caused dysplasia or neoplasia and sporadic adenoma or carcinoma is essential, since one diagnosis warrants total colectomy while the other can be treated with local excision.